Evaluation of coagulation tests before newborn circumcision: is it necessary?

Is hyperbilirubinemia a contraindication for neonatal circumcision? A survey of practice patterns of pediatric urologists and a review of the literature

INTRODUCTION AND OBJECTIVE

50-80% of term newborns develop jaundice, or hyperbilirubinemia (HB), in their first week. The vast majority have benign etiologies, including physiologic jaundice of the newborn and breast milk/breastfeeding jaundice, which do not affect the synthetic capacity of the liver, thus conferring a low risk of peri-procedural bleeding. Though uncommon, HB in the setting of sepsis, biliary obstruction, or metabolic disease, may increase procedural bleeding risk. Circumcision of neonates with HB has not been well studied. We sought to characterize practice patterns among Society of Pediatric Urology (SPU) members and to explore whether HB confers increased bleeding risk for newborn circumcision.

METHODS

An anonymous survey of 14 multiple-choice questions was sent to members of the SPU listserv. Questions regarding circumcision and HB were presented. We performed a literature review regarding whether HB confers increased surgical bleeding risk.

RESULTS

100/234 (43%) SPU members completed the survey. The majority (79/100) perform neonatal circumcision and use the Gomco© clamp (68%). 24/79 (30%) factor total bilirubin (Tbili) level in their decision prior to performing circumcision. Of those who consider HB a factor, 11/24 (46%) had cutoff Tbili levels at which they await improvement prior to proceeding. The most common cutoff level was Tbili level of 10-15 mg/dL (6/11, 55%).

DISCUSSION

Existing data suggest a possible increased bleeding risk isolated to cases of HB in the setting of biliary obstruction or other associated relevant findings (ill infant, recent infection, congenital syndromes) or known personal/family history (fulminant liver disease, familial bleeding diatheses). While literature from Jewish Mohels and Talmudic discussion suggest that elevated Tbili may be a contraindication to circumcision, no scientific studies exist directly assessing the impact of HB on bleeding risk with circumcision. A review of the scientific literature suggests that isolated HB in otherwise healthy newborns does not increase bleeding risk.

CONCLUSIONS

30% of pediatric urologists survey respondents consider HB a potential contraindication to neonatal circumcision. Despite varied practices in circumcising jaundiced babies, neonatal jaundice rarely confers increased bleeding risks. While deferring circumcision is appropriate in an ill infant with HB, or in those with a genetic/congenital syndrome or with family history of coagulopathic, review of the scientific literature suggests that in otherwise healthy neonates, elevated Tbili likely represents benign causes and is unlikely to increase bleeding risk.

Complication of newborn circumcision: Meatal stenosis or meatal web?

INTRODUCTION

Meatal stenosis (MS) is a known complication of newborn circumcision. Symptoms are usually masked in young kids with a diaper. Deflation of urinary stream, dysuria, urinary frequency, and incontinence are the most common reported symptoms. Diagnosis of MS is still controversial. A narrow pinpoint urethral meatus is the current accepted diagnostic criteria.

OBJECTIVE

In our practice, we observed that our cases do not overlap to the classic definition and presentation of MS. In this study, we presented our cases and aimed to share our observations.

MATERIALS AND METHODS

Records of children who had meatoplasty between 2014 with 2016 were analyzed retrospectively. Only children with MS who had had newborn circumcision performed in our clinic were included in the study. Over 500 newborn circumcisions are performed per year in our clinic using the Gomco Clamp technique. Age at diagnosis, presenting complaints, penile anomalies including urethral meatus configuration, urinary symptoms, operation methods, and postoperative follow-up were gathered.

RESULTS

A total of 13 boys who were circumcised in the newborn period had undergone meatoplasty with the diagnosis of MS. The mean age at the time of meatoplasty was 52.5 ± 17.9 (range 37-93 months). All children were examined before and during the circumcision. There were no associated penile anomalies, including MS. The only presenting complaint was upward deflation of urinary stream instead of other lower urinary tract symptoms. Although the appearance of the meatus was pinpoint in all cases (Figure); it was easy to calibrate with an 8-10 Fr feeding tube. There was no stenosis, but a ventral web was detected. Meatoplasty with removal of this web was performed under general anesthesia. Two sutures were applied at 5 and 7 o'clock with 7/0 PDS. Mean postoperative follow-up time was 16.9 ± 7.5 months. Children were pleased with direction of urinary stream.

DISCUSSION

Both the diagnosis and morphological definition of MS have some controversies. To our knowledge, there is no similar reported study with pinpoint appearance and normal calibration of the meatus. There was no stenosis in any of them. Unlike classical MS presentations, upward deflation of urinary stream resulting from ventral web was a single presenting complaint.

CONCLUSIONS

Upward deflation of urinary stream can develop after neonatal circumcision because of a meatal web without stenosis, and can be cured easily with meatoplasty. Instead of 'meatal stenosis', 'meatal web' may be a more appropriate term to explain the pathology in these patients.

Epidemiology of preoperative hematologic assessment of children cared for in a pediatric emergency department

OBJECTIVE

To assess frequency of preoperative hematologic testing in a tertiary care pediatric emergency department (PED) and how often these values predict clinical outcome or change management decisions.

METHODS

Single-center retrospective cohort study in a tertiary-care children's hospital PED. Patients 0-18years old, presenting between July 1, 2009-July 1, 2011, ultimately undergoing a surgical procedure within 48h of presentation were included. Patients were defined as having "preoperative" hematologic assessment if these studies were performed solely because the child was going to the operative suite. Patients who met trauma team activation criteria, underwent neurosurgical procedures, or had laboratory studies performed prior to PED arrival were excluded. The primary outcome was the prevalence of preoperative laboratory assessment.

RESULTS

528 children were included, of whom 301 (57%) underwent preoperative hematologic laboratory evaluations. Of these 301 patients, 115 (38%) had abnormal hematologic parameters, and only 3 (1%) of these patients had their perioperative management changed. One additional child had intraoperative bleeding that required blood products but did not undergo preoperative hematologic assessment. All four children had medical histories that would have identified their risk for perioperative bleeding events.

CONCLUSION

Preoperative hematologic laboratory assessment occurs frequently in children initially cared for in a tertiary care pediatric emergency department who subsequently undergo operative interventions. Although age-based abnormal hematologic values are often found, rarely are these abnormalities clinically significant. This study suggests that children cared for in a PED without a history concerning for an increased risk of perioperative bleeding does not require preoperative hematologic assessment.

Post-ritual Circumcision Bleeding-Characteristics and Treatment Outcome

OBJECTIVE

To report the characteristics, treatment, and short-term outcome of neonatal post-circumcision bleeding, and to identify predictors of surgical treatment.

MATERIALS AND METHODS

The medical records of 90 consecutive neonates who presented to the emergency room with post-circumcision bleeding between 2009 and 2014 were reviewed. Circumcisions were performed using the traditional Mogen shield device. The study end point was surgical intervention for hemostasis. Predictors of surgical treatment were evaluated.

RESULTS

An estimated total of 28,383 circumcisions were performed during the study period; thus, the post-circumcision bleeding rate was 0.32%. Initial treatment included compressive dressing in 15 infants (17%) and hemostatic dressing in 47 infants (52%); 28 infants (31%) did not require treatment upon arrival to the emergency room. Two infants (2%) received blood transfusion. Surgical treatment was required in 11 infants (12%); 10 of 43 infants (23%) with active bleeding on arrival to the emergency room required surgery compared to 1 of 47 infants (2%) without active bleeding (P = .003). Similarly, 3 of 7 infants (43%) referred from other hospitals required surgery compared to 8 of 83 infants (10%) referred from the community (P = .037). Abnormal blood tests at presentation were not associated with surgical treatment. At 1 month of follow-up, 2 infants were admitted for recurrent bleeding. Coagulation abnormalities were found in 4 infants.

CONCLUSION

Surgical treatment was required in 12% of infants presenting to the emergency room with post-circumcision bleeding. The rate of surgical intervention was significantly higher in infants with active bleeding at presentation and in those referred from other hospitals. Physicians should consider admitting infants presenting with active post-circumcision bleeding, whereas infants without active bleeding may be observed and discharged.